Tag Archives: Patient Safety

A physician in our family recommended “How Doctors Think” by Jerome Groopman. Dr. Goopman’s book will give you insights that will serve you well for the rest of your life (and could help you survive longer too). Diagnosis can be very challenging – personally I hope not to be one of those difficult cases. But even everyday cases can be misdiagnosed – and the US system is poorly equipped to detect and correct these errors.

Recently Laura Landro, writing for WSJ, surveyed the current US situation. The graphic at left gives just a glimpse of how serious the problem is. There are no large-scale studies, in part because accurate results would be very expensive to obtain. How do you detect an incorrect diagnosis? How do you know the consequences if you detect such a case?

Perhaps most importantly, how does the patient get access to profiles of doctors and institutions so they can avoid “Dr. Death” and improve their chances of good treatment? Here’s an abbreviated excerpt of Ms Landro’s report (bear in mind the data presented is one study of 190 cases):

“Diagnostic error is probably the biggest patient-safety issue we face in health care, and it is finally getting on the radar of the patient quality and safety movement,” says Mark Graber, a longtime Veterans Administration physician and a fellow at the nonprofit research group RTI International.

(…snip…)

In addition, the Society to Improve Diagnosis in Medicine, which Dr. Graber founded two years ago, is working with health-care accreditation groups and safety organizations to develop methods to identify and measure diagnostic errors, which often aren’t revealed unless there is a lawsuit. In addition, it’s developing a medical-school curriculum to help trainees improve diagnostic skills and assess their competency.

(…snip…)

Large health-care systems are mining their electronic records for missed signals. At the Southern California Permanente Medical Group, part of managed-care giant Kaiser Permanente, a “Safety Net” program periodically surveys its database of 3.6 million members to catch lab results and other data that might fall through the cracks.

In one of the first uses of the system, a case manager reviewed 8,076 patients with abnormal PSA test results for prostate cancer, and more than 2,200 patients had follow-up biopsies. From 2006 to 2009, 745 cancers were diagnosed among those patients—and Kaiser had no malpractice claims related to missed PSA tests.

The program is also being used to find patients with undiagnosed kidney disease, which is often found via an abnormal test result for creatinine, which should be repeated within 90 days. From 2007 to 2012, the system found 7,218 lab orders placed for patients with an abnormal test that had not been repeated. Of those, 3,465 were repeated within 90 days of a notice to patients that they needed a repeat test, and 1,768 showed abnormal results. The majority, 1,624, turned out to be new cases of the disease.

Michael Kanter, regional medical director of quality and clinical analysis, says the system enables clinicians to go back “as far as is feasible to find all of the errors that we can and fix them.”

One of the many things I learned from Dr. Marty Makary, author of Unaccountable, is how difficult it often is to obtain a correct diagnosis. It is sufficiently challenging that at least one startup is trying to make a business out of the “diagnosis/therapy gap” – the Peter Thiel-backed Metamed. It is way too early to assess how effective Metamed will be, but you should bookmark the reference. Here’s an excerpt from Venture Beat:

Futurist and entrepreneur Michael Vassar has an issue with the U.S. medical system. He hopes to “humiliate” it into providing better quality care by creating a “product that works better than the system.”

With $500,000 in startup investment from PayPal cofounder Peter Thiel, he has handpicked a crack team of physicians and software engineers (including Skype founder Jaan Tallinn) for a new health care company called MetaMed. The goal is to leverage data and statistics to take the guesswork out of medicine.

“It seems very possible to add 10 or 20 years of healthy life expectancy to a person who gathers all the relevant data today,” said Vassar in an interview with VentureBeat.

(…snip…)

The idea for MetaMed was formed when Vassar was the president of the Singularity Institute, a research organization focused on the field of Artificial Intelligence.

At that time, Steve Jobs was suffering from pancreatic cancer, prompting Vassar to consider a scenario in which the late Apple CEO brought together Nobel Prize-winning scientists and physicians from around the world to consider his case. “That is the solution we are trying to create with MetaMed,” he said.

It makes me happy to drill down into a NZ government healthcare-safety website to find a link to Atul Gawande’s TED Talk How do we heal medicine? That is just an indicator, but a positive indicator, that NZ is paying attention to developments in methods to radically improve medical safety. For those who are new to this topic, this earlier post links to important resources: How to Stop Hospitals From Killing Us.

The Commission is developing a work programme to help implement the Global Trigger Tools programme in New Zealand.

The Global Trigger Tools* programme is an international initiative to reduce patient harm caused by errors in hospitals. Currently most health service providers rely on voluntary reporting of errors to identify problems in their systems, however overseas research found that only 10-20 percent of errors are ever reported. While in the vast majority of cases these errors did not result in patient harm, tracking these events would help identify where improvements should be made.

The Global Trigger Tools programme takes a different approach to error reporting, rather than relying on people reporting errors, it analyses random samples of patient records looking for ‘triggers’ which indicate an error has been made. The information gained can then be used to improve the quality and safety of the services provided.

Carol Haraden is the Vice President of the Institute of Healthcare Improvement (IHI). IHI developed the Global Trigger Tool which the Commission is encouraging all DHBs to implement. The Commission is working to publish helpful resources to assist with implementation. In the short AV below, Carol is interviewed at the Asia Pacific Forum (APAC) on patient safety and asks why clinicians aren’t using a standardised approach to patient safety issues. She also talks about the importance of team-work in achieving improved patient safety.

The Global Trigger Tool has a focus on team-work as the methodology requires medical record reviews to be carried out by a team of trained reviewers who have a clinical background (usually nursing or pharmacy). This is a simple, validated, and cost effective methodology and has been widely used to identify, quantify and track patient harm.

The use of “triggers,” or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm in a health care organization. The IHI Global Trigger Tool for Measuring AEs provides instructions for training reviewers in this methodology and conducting a retrospective review of patient records using triggers to identify possible AEs. This tool includes a list of known AE triggers as well as instructions for selecting records, training information, and appendices with references and common questions. The tool provides instructions and forms for collecting the data you need to track three measures:

Measuring safety is crucial to improving health care, yet we still struggle to do it well.

Much of the challenge lies in safetys very nature: it is, inherently, a non-event—the absence of harm. So by necessity we focus instead on measuring what might be called ‘non-safety,’ usually in the form of harmful events. Fewer of these harmful events, we assume, means a safer health care system.

But which events do we count? How do you tally non-safety?

Our answer to that simple question is hugely consequential. Some efforts focus on infections, for instance. These are crucial harm events, but they are not the whole picture. Their absence does not, in and of itself, tell us that care delivery is safe.

At IHI, we’ve developed a freely available method of determining harm events that we call The Global Trigger Tool. Its advantage is comprehensiveness. Its drawback is time-intensiveness. We believe it’s a trade-off worth making. Here’s how the method works, as described in a recent Health Affairs paper:

‘Closed patient charts are reviewed by two or three employees —usually nurses and pharmacists, who are trained to review the charts in a systematic manner by looking at discharge codes, discharge summaries, medications, lab results, operation records, nursing notes, physician progress notes, and other notes or comments to determine whether there is a ‘trigger’ in the chart. A trigger could be a notation indicating, for example, a burn, a fall, or a reaction to a medication. Any notation of a trigger leads to further investigation into whether an adverse event occurred and how severe the event was. A physician ultimately has to examine and sign off on this chart review.’

We tested this system against other widely used methods to detect adverse events, and the results were stunning. The trigger tool detected 354 adverse events, while tools based on automated chart review fared far worse. The Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators detected only 35 adverse events. The hospitals’ voluntary reporting systems? Just four.

You’ve all heard the old iceberg trope – 10 percent above water, 90 percent below. Well here it is, in sobering statistics. And those errors that occur below the water line of measurement aren’t actually invisible – not to patients, not to their families, and not to providers or to the functioning of our health care system.

The trigger tool is less time intensive than some other chart review methods, but as I mentioned earlier, it is not as cheap as automated methods such as AHRQ’s Patient Safety Indicators. Manual review simply takes more time. There is no way around that.

But nor is there a way around the danger of missing so many adverse events. Think about what other audits you conducting at your hospital that may be just as time-intensive. Surely, safety should rate the same level of attention and commitment.

So we want to hear from you:

How do you measure harm in your organization?

Do you believe that you are capturing the entire scope of harm?

The good news, from our perspective, is that hospitals and regulators are increasingly using the trigger tool to identify the broader universe of adverse events. We will keep working to continue this trend—because only by facing the reality of adverse events can we truly address them.

In the UK, The Acute Trigger Tool is the approved UK version of IHI Global Trigger Tool. Again, lots of resources from the UK NHS Institute for Innovation and Improvement.

Improvement in health care quality and safety can be notable when measurement criteria are clear, evidence is strong, and policy and interventions are focused. Despite this potential, progress in reducing patient harm in hospitals has been slow.1 In an effort to catalyze progress, the Department of Health and Human Services (HHS) is funding a national program, Partnership for Patients (P4P), with the ambitious goal of reducing “preventable hospital-acquired conditions” by 40% by 2013, focused initially on 9 complications.2 Although the program’s goal formally includes only preventable harm, the HHS notes “the Partnership will target all forms of harm” and provide guidance to hospitals for reducing “all-cause harm.” Simultaneously, the list of “serious reportable events” for which the Centers for Medicare & Medicaid Services will modify physician and health care institution payment is increasing. However, delay in defining a measurement strategy for harm has slowed progress and has created confusion. The need to reach consensus on robust, pragmatic measures for assessing and tracking harm rates has therefore become urgent.

Have you ever been caught between loyalty to another physician whose skills you don’t respect, and wanting to warn a patient if you knew they were scheduled to have a procedure performed by that physician?

Roughly a quarter of all hospitalized patients will be harmed by a medical error of some kind. If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer’s.

(…) As doctors, we swear to do no harm. But on the job we soon absorb another unspoken rule: to overlook the mistakes of our colleagues. The problem is vast. U.S. surgeons operate on the wrong body part as often as 40 times a week. Roughly a quarter of all hospitalized patients will be harmed by a medical error of some kind. If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer’s. The human toll aside, medical errors cost the U.S. health-care system tens of billions a year. Some 20% to 30% of all medications, tests and procedures are unnecessary, according to research done by medical specialists, surveying their own fields. What other industry misses the mark this often?

It does not have to be this way. A new generation of doctors and patients is trying to achieve greater transparency in the health-care system, and new technology makes it more achievable than ever before.

I encountered the disturbing closed-door culture of American medicine on my very first day as a student at one of Harvard Medical School’s prestigious affiliated teaching hospitals. Wearing a new white medical coat that was still creased from its packaging, I walked the halls marveling at the portraits of doctors past and present. On rounds that day, members of my resident team repeatedly referred to one well-known surgeon as “Dr. Hodad.” I hadn’t heard of a surgeon by that name. Finally, I inquired. “Hodad,” it turned out, was a nickname. A fellow student whispered: “It stands for Hands of Death and Destruction.”

Stunned, I soon saw just how scary the works of his hands were. His operating skills were hasty and slipshod, and his patients frequently suffered complications. This was a man who simply should not have been allowed to touch patients. But his bedside manner was impeccable (in fact, I try to emulate it to this day). He was charming. Celebrities requested him for operations. His patients worshiped him. When faced with excessive surgery time and extended hospitalizations, they just chalked up their misfortunes to fate.

(…) The disease control agency estimates there are 1.7 million infection cases a year in hospitals and that 99,000 patients die after contracting them (although infection may not be the sole cause). It projects the cost of treating those patients at $20 billion a year.

Despite the daunting statistics, and what would seem to be the ease of saving thousands of lives, old habits have proven stubbornly resistant to cultural change. Research has found that constant vigilance, individualized solutions and an upending of hospital hierarchy are all required.

“It seems really simple, but even this one turns out to be complicated,” Dr. Chassin said in an interview.

(…) Another surprising example was at Cedars‐Sinai Medical Center. The surveillance team cultured everything in the patient environment and discovered that privacy curtains—required around all patient beds in California—were colonized with multi‐drug resistant organisms in some rooms. According to chief medical officer Michael Langberg, MD, the information “stunned” them. “Patients in the room did not have infections, but the organisms were sitting on the privacy curtains,” he said. Even if health care personnel were doing effective hand hygiene before walking in the room, they might touch the curtains without realizing it. The hospital swapped out every curtain and changed how and when they cleaned them. Subsequently, zero such organisms have grown on the curtains, said Langberg. This hospital also addressed the potential spread of germs on lab coats by adding hooks outside patient rooms, which allows health care personnel to easily remove their coats before entering a room.

(…) By bundling supplies and tasks, health care personnel have fewer opportunities to be in patient rooms and fewer opportunities when they need to wash their hands, likely increasing compliance. “We looked at workflow and how to standardize it, so we decreased ins and outs of patient rooms,” said Miller. Changing the location of dispensers to fit in people’s workflow also increased compliance.

(…) Since June 2010, Virtua has been piloting technology and sensors worn by all health care providers. “Technology is making us look at our process,” said Kate Gillespie, RN, Six Sigma black belt. Though the hospital is still fine‐tuning that technology, Gillespie believes that in the long term, using technology will be helpful. “We cannot sustain secret observers,” she said. But having the technology has shown them their observations were “not that far off.” “We can see a correlation,” she added.

WFUBMC also focused on using an electronic method to monitor and increase compliance for hand hygiene. Health care personnel wear a real time location system tag equipped with infrared recognition that is activated when entering a patient care area. The tracker on the hand sanitizers, sinks, or pumps reads the tag and reports the activation. Tony Oliphant, RN, nurse manager, emphasized that the goal for the technology is that it does not interfere with the workflow. The badges are being modified so as not to hinder work. “We didn’t want to change the way people enter and exit rooms,” Oliphant said.

The new technology and its possibilities are “monumental in nature,” said Shayn Martin, MD, WFUBMC. “We are creating a system to track providers to perform hand hygiene on a scale that is substantially greater than our existing systems. It is continuous. It allows us to build reports for individual compliance.” He added, “We should be 100 percent compliant with hand hygiene. We want to be sure the system is highly accurate, does not give false data and does not impose on workflow.” Though using this technology “sounds big brother‐like,” Martin acknowledged, “the last thing we want is to create an environment that makes people nervous and makes it harder to do their job….[The technology] is a way to approach 100 percent [compliance].”

(…) Johns Hopkins Hospital also used red lines at the thresholds to all patient rooms to serve as a reminder to “wash or don’t cross,” said Kulik. At Memorial Hermann The Woodlands, the door thresholds in the ICUs have red tape that goes up the side of the door with an arrow pointing to where the hand sanitizer is located. That area is marked “patient zone” to remind health care personnel and all visitors that they are crossing this threshold and should clean their hands. “We know hand hygiene has become a habit when a serious situation develops in the ICU and we see health care providers pause in the doorway to get hand sanitizer,” said Parks. “It is the last point at which a health care worker can get it right and prevent infection,” observed Rob Morehead, RN, infection control practitioner. “If we wash hands, we can still get it right,” he added.

This photo is one of several developed for the Cedars-Sinai hand-hygiene campaign. There is an excellent, short Freakonomics podcast on the topic — highly recommended. And 25 January there is a brief update with links to some of the humorous Cedars-Sinai campaign materials. This campaign is directed by their “Zero Hospital-Acquired Infections Task Force”.

This is such a critical topic — a topic that hospitals largely do not wish to discuss. Few hospitals are as serious as Cedars-Sinai. Few hospitals know how many of their doctors practice adequate hand-hygiene. As patients how do we protect ourselves from the dirty doctors and all the other hospital pathways to infection?

There are a few public documents coming out of Cedars-Sinai, though I’ve not found any publications on their current infection control performance, or policies/procedures (other than OR surgical hand scrub, but I don’t think the OR is where the problem is). In one of their pubs on MRSA, Super Staph, on the effects of anti-cholesterol drug BPH-652, there is a sidebar outlining the hand-washing campaign:

The Best Weapon, Hands Down.

The rule is clear: Doctors and nurses are supposed to wash their hands or use a Purell® dispenser before they enter and leave a patient room. For various reasons—not only at Cedars-Sinai but at hospitals everywhere—compliance with this rule falls short of the 100 percent goal. Sometimes, in the rush to get to the next patient, healthcare professionals simply forget to wash their hands. Or they might figure it’s not necessary because they were only in a patient’s room briefly and didn’t touch anything.

Making sure everyone complies with hand-washing guidelines without fail is the goal of a hospital-wide campaign at Cedars-Sinai that involves educating all employees, as well as patients and visitors, about the fact that hand hygiene can, indeed, save lives. New custom-designed kiosks in visitor waiting areas provide Purell® dispensers, masks and tissues and display the message, “The power is in your hands. Please help us protect our patients’ health.”

Erica Palys, MD, an infectious disease fellow who helps lead the hospital’s hand hygiene task force, says trying to get people to change their routine is a challenge, especially when they can’t directly see the results of their actions. “If you don’t wash your hands, there is no visible consequence—you don’t see that person down the line who could get sick or die. We’re making hand hygiene as convenient as possible so that it becomes easy to do the right thing without even thinking about it.”

In the same bulletin see also the informative “Staff vs. Staph” sidebar which closes with this:

“It all comes down to a common goal,” notes Dr. Langberg, who devotes five to 10 hours a week to the task force. “We realized that if anyone of us is a patient coming to the hospital we shouldn’t walk out with a bug we didn’t have. It’s a priority for all of us.”

Could technology help us overcome this human-social challenge? I think so, read on…

A little bit of followup on our previous post on hospital hand-hygience. Eliminating hospital-acquired infections requires achieving a nearly perfect performance on many different fronts. From quarantine of suspect new admissions (e.g., nursing home patients), staff hand-hygiene, to efficient forensic analysis when the presence of an infection is discovered. The latter case illustrates to me the potentially enormous impact that technology might have on the infection control and the larger issue of medical errors.

The Freakonomics podcast that motivated my little bit of research mentioned the potential application of automated location tracking. First, imagine that every patient, every staff member, every piece of equipment, every parcel of drugs or apparatus is identified and real-time located by an RFID tag. An almost trivial application of that real time information is described in this vendor promotion Elpas Hand Hygiene Compliance Monitoring Solution:

(…) Each caregiver is issued an Elpas Active Identity Badge. So when the caregiver uses a hand washing station or sanitizer, a nearby Elpas LF Exciter triggers the personal badge tag worn by the caregiver to transmit hand washing event messages that identifies the caregiver and the time that the specific dispenser was used.

Hospital administrators can use the Elpas Hand Hygiene Solution to generate detailed compliance reports per caregiver or per examination room. This documentation can be beneficial in monitoring staff compliance with hospital hand hygiene policies and to trace the source of infection transfers.

The Elpas Hand Hygiene Solution can also alert administrators of non-compliance incidents in real-time as well as alerting those caregivers to their non-compliant status prior to providing care.

So the system can alert the doctor that they need to rectify their hygiene before contacting this patient; and of course can perform logging of compliance exceptions. With this feedback, and the appropriate hospital administration priorities, soon there won’t be any un-corrected exceptions.

Now, imagine a hypothetical infection case: a patient is discovered to be infected with MRSA. Besides quarantine and treatment, one would expect the hospital staff to urgently want to know “How did this happen? “. Who and what has been in contact with this patient during the time window of possible infection? The imagined RTLS system will “know” the time-location web of interactions involving this patient. Just one of the more obvious questions comes back to the hand-hygiene topic: were there compliance exceptions for any of the staff interacting with the infected patient? That knowledge would at least guide us to give high priority to those staff (I have no idea what best practice reactions are to this sort of case).

If Sebastian Thrun and colleagues can program a self-driving car, it won’t be long before the technical capability exists to produce in seconds an analysis of the time-location history, allowing hospital response staff to establish possible infection-sources ranked from most- to least-probable. Is it a fixed contamination (staff coffee maker, elevator); a staffer; a mobile blood-pressure monitor? How many hours/days does it take today when humans have to paw through reams of paper records to reconstruct the time-location history? The longer it takes to solve the puzzle the more infections.

There are already a number of competitors entering this field. Deployment seems to be starting with the easy and obvious: tracking hospital equipment and supplies, etc. – i.e., Walmart comes to hospital inventory control. Next seems to be error prevention priorities (is the correct patient about to get an amputation of the correct limb?; correct drug delivery?; etc.).

So far I’ve not found any public case study information demonstrating important successes in infection control or medical errors from an RTLS implementation – but I am hopeful. If not RTLS, then we need some another impartial technology to overcome our human fallibility. Meanwhile, more people will continue to die (in the US) from hospital-acquired infections than from AIDs.

Last month, health inspectors in New York City shut down Serendipity, an upscale ice cream parlor. Though the closing made headlines, it is a common occurrence for less-famous eateries charged with violations like unclean cutting boards and floors, workers who fail to clean their hands, and improper food handling that could lead to bacterial contamination.

Restaurants in New York are inspected, without prior notice, once a year. In Los Angeles, inspections are done three times a year, and restaurants must display their grade near the front door. After L.A. instituted this inspection system in 1998, the number of people sickened by food-borne illnesses fell 13%, according to the Journal of Environmental Health. Other cities are now following L.A.’s lead.

Why aren’t hospitals held to the same rigorous standard? The consequences of inadequate hygiene are far deadlier in hospitals than in restaurants. The Centers for Disease Control and Prevention estimate that 2,500 people die each year after picking up a food-borne illness in a restaurant or prepared food store. Forty times that number — 100,000 people — die each year, according to the CDC, from infections contracted in health-care facilities.

Data recently published by the Journal of the American Medical Association show that infections from just one type of bacteria — methicillin-resistant Staphylococcus aureus (MRSA) — kill about twice as many people in the U.S. as previously thought. The finding is based on lab tests, not on what hospitals report. If the same methodology were used to quantify deaths from all hospital infections, the death toll would likely be much larger than 100,000.

These infections are caused largely by unclean hands, inadequately cleaned equipment and contaminated clothing that allow bacteria to spread from patient to patient. In a study released in April, Boston University researchers examining 49 operating rooms at four New England hospitals found that more than half the objects that should have been disinfected were overlooked by cleaners.

…That is why RID was founded: to motivate hospitals to make infection prevention a top priority and to show them the financial benefits of doing so; to provide patients with information on how to protect themselves; and to educate future doctors and nurses on the precautions needed to stop bacteria from spreading patient to patient.

Many hospital administrators believe they can’t afford to take these precautions. They can’t afford not to! Infections erode hospital profits. When a patient contracts an infection and stays in the hospital weeks or even months longer, the hospital is seldom paid for the added stay and care. RID’s research provides compelling economic evidence that preventing infections can cost far less than treating them.

RID is also creating educational tools for medical and nursing schools. It’s hard to believe, but young doctors and nurses in training seldom have even one class session devoted to hygiene. Educating the future generation of caregivers about hygiene and making it a central part of medicine again may be RID’s most lasting legacy.

Finally, better infection control in hospitals is essential to prepare the nation for avian flu or bioterrorism. If hospitals have effective infection controls in place, they can prevent bird flu victims from infecting other patients who did not come in with it. If not, bird flu could sweep through hospitals. Right now, most hospitals are woefully under prepared.

How can hospitals that have failed to contain ordinary infections spread by touch control a flu virus that is communicated by droplets from coughing and sneezing as well as touch? Even more challenging would be small pox, plague, and other bioterrorism weapons that can travel through the air. Shoddy infection control is poor preparation for a flu epidemic and poor homeland security as well.

Ideally, you would choose a hospital with a low infection rate. Good luck getting that information. It’s impossible. Many states collect data on infections that lead to serious injury or death, but nearly every state-with the exception of 6-has given into the hospital industry’s demands to keep the information secret. The federal Centers for Disease Control and Prevention also collect infection data from hospitals across the nation, but refuse to make it public. Government is too often on our backs, instead of on our side.

What’s the answer? Hospital infections report cards. Hospitals object that comparisons would be unfair because hospitals that treat sicker patients, such as AIDS, cancer, and transplant patients who have weakened immune systems, will have a higher infection rate. True, but the data can be risk adjusted to make comparisons fair. What is unfair is preventing the public from knowing which hospitals have infection epidemics. Keeping infection rates secret may help hospitals save face, but it won’t save lives.